When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Palpate the radial pulses in both arms for a deficit.

Use the stethoscope to listen over the carotid artery.

Feel the volume of the dorsalis pedis and posterior tibialis pulses.

Auscultate the apical pulse at the point of maximal impulse.

Answer and Explanation

The Correct Answer is D

A.   Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B.   Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C.   Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D.   Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

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Correct Answer is B

Explanation

A. A hernia may present as a bulge in the abdomen, but it is not typically pulsating. It is usually a soft, non-pulsatile mass.
B. A pulsating centrally localized abdominal distention is characteristic of an abdominal aneurysm, which occurs when the wall of the aorta weakens and bulges. The pulsation is often palpable and can be dangerous if ruptured.
C. Tympany refers to a sound produced during percussion, which is typically heard over air-filled structures like the stomach, but it doesn’t cause pulsating distention.
D. Appendicitis typically presents with localized pain in the lower right abdomen and is not associated with pulsating abdominal distention.

A. Flexion B. Adduction C. Abduction D. Extension

Correct Answer is ["A","C"]

Explanation

WRIST - ABLE TO BEND WRIST BACK TOWARD FOREARM:

Abduction

Abduction refers to the movement of a body part away from the body's midline. This movement is typically used for fingers, arms, or legs, but not for the wrist. Therefore, this choice is incorrect for the wrist's range of motion.

Flexion

Flexion refers to the bending of a joint that reduces the angle between two body parts. For the wrist, flexion would involve bending the wrist forward, toward the palm of the hand. Since the patient is able to bend the wrist backward (toward the forearm), this is not the correct choice.

Extension

Extension refers to straightening a joint, which increases the angle between the body parts. For the wrist, extension is the movement where the hand moves away from the palm (backward toward the forearm). This is the correct choice because the patient is able to bend the wrist back toward the forearm, which is extension.

Adduction

Adduction refers to the movement of a body part toward the body's midline. This is not relevant to the wrist, so it is an incorrect option.

SHOULDER - UNABLE TO MOVE THE ARM AWAY FROM THE BODY:

Extension

Extension refers to the movement that straightens a joint, increasing the angle between two parts of the body. For the shoulder, this would involve moving the arm behind the body, and it's not the movement of the arm away from the body, so this is not the correct choice.

Adduction

Adduction refers to moving a body part toward the midline of the body. For the shoulder, this would involve moving the arm closer to the body. This does not correspond to the action of moving the arm away from the body, so this is not the correct choice either.

Flexion

Flexion refers to the bending of a joint that decreases the angle between two body parts. For the shoulder, this would involve raising the arm forward, not moving it away from the body. This is not the correct choice for the described movement.

Abduction

Abduction refers to the movement of a body part away from the midline of the body. In this case, the shoulder movement of moving the arm away from the body is abduction. Since the client is unable to move the arm away from the body (i.e., is experiencing weakness or limited ROM), the shoulder’s range of motion has a restriction in abduction.

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When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is ["A","C"]

Explanation

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